Medicine
®
OBSERVATIONAL STUDY
A Retrospective Cohort Study Comparing Stroke Recurrence Rate in Ischemic Stroke Patients With and Without Acupuncture Treatment Chun-Chuan Shih, MD, PhD, Chien-Chang Liao, PhD, MPH, Mao-Feng Sun, MD, PhD, Yi-Chang Su, MD, PhD, Chi-Pang Wen, MD, PhD, Donald E. Morisky, ScD, Fung-Chang Sung, PhD, MPH, Chung Y. Hsu, MD, PhD, and Jaung-Geng Lin, MD, PhD
Abstract: Little was known about the effects of acupuncture on stroke recurrence. The aim of this study is to investigate whether ischemic stroke patients receiving acupuncture treatment have a decreased risk of stroke recurrence. A retrospective cohort study of 30,058 newly diagnosed cases of ischemic stroke in 2000 to 2004 was conducted based on the claims of Taiwan National Health Insurance Research Database. The use of acupuncture treatment and stroke recurrence were identified during the follow-up period from 2000 to 2009. This study compared the risk of stroke recurrence between ischemic stroke cohorts with and without acupuncture treatment by calculating adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of acupuncture associated with stroke recurrence in the Cox proportional hazard model. The stroke recurrence rate per 1000 person-years decreased from 71.4 without to 69.9 with acupuncture treatment (P < 0.001). Acupuncture treatment was associated with reduced risk of stroke recurrence (HR Editor: Sarah Fogarty. Received: June 21, 2015; revised: August 13, 2015; accepted: August 19, 2015. From The School of Chinese Medicine for Post-Baccalaureate, I-Shou University, Kaohsiung (CCS); Ph.D. Program for the Clinical Drug Discovery from Botanical Herbs, Taipei Medical University (CCS); Department of Anesthesiology, Taipei Medical University Hospital, Taipei (CCL); School of Chinese Medicine, (CCL, MFS, YCS, JGL); Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan (CPW, CYH); Fielding School of Public Health University of California, Los Angeles, California (DEM); Department of Public Health, China Medical University (FCS); and Department of Neurology, China Medical University Hospital, Taichung, Taiwan (CYH). Correspondence: Jaung-Geng Lin, School of Chinese Medicine, China Medical University, 91 Hsueh-Shih Road, Taichung 404, Taiwan (e-mail: [email protected]). This study is based in part on data obtained from the National Health Insurance Research Database provided by the Bureau of National Health Insurance, Department of Health and managed by the National Health Research Institutes. The interpretation and conclusions contained herein do not represent those of the Bureau of National Health Insurance, Department of Health, or National Health Research Institutes. Dr C-CL has equal contribution with the first author. This study was supported in part by Committee on Chinese Medicine and Pharmacy, Department of Health, Taiwan (CCMP99-RD-035), Taiwan Ministry of Science and Technology (MOST103-2320-B-214-010MY2), Taiwan Ministry of Health and Welfare Clinical Trial and Research Center of Excellence (MOHW104-TDU-B-212-113002), China Medical University Hospital, Academia Sinica Taiwan Biobank Stroke Biosignature Project (BM104010092), NRPB Stroke Clinical Trial Consortium (MOST 103-2325-B-039-006), Tseng-Lien Lin Foundation and the Katsuzo and Kiyo Aoshima Funds, Japan. The authors have no conflicts of interest to disclose. Copyright # 2015 Wolters Kluwer Health, Inc. All rights reserved. This is an open access article distributed under the Creative Commons Attribution- NonCommercial License, where it is permissible to download, share and reproduce the work in any medium, provided it is properly cited. The work cannot be used commercially. ISSN: 0025-7974 DOI: 10.1097/MD.0000000000001572
Medicine
Volume 94, Number 39, October 2015
0.88; 95% CI 0.84–0.91). The acupuncture effect was noted in patients with or without medical treatment for stroke prevention but its impact decreased with aging of stroke patients. Compared with stroke patients without acupuncture treatment and medication therapy, the hazard ratios of stroke recurrence for those had medication therapy only, acupuncture only, and both were 0.42 (95% CI 0.38–0.46), 0.50 (95% CI 0.43–0.57), and 0.39 (95% CI 0.35–0.43), respectively. This study raises the possibility that acupuncture might be effective in lowering stroke recurrence rate even in those on medications for stroke prevention. Results suggest the need of prospective sham-controlled and randomized trials to establish the efficacy of acupuncture in preventing stroke. (Medicine 94(39):e1572) Abbreviations: CI = confidence interval, HR = hazard ratio, ICD9-CM = International Classification of Diseases, 9th Revision, Clinical Modification, NHI = National Health Insurance.
INTRODUCTION
S
troke remains a leading cause of death and the leading cause of disability worldwide.1 The costs of stroke to the family and the society underscore the importance of stroke prevention and management. Secondary stroke prevention remains a top priority in treating patients after the first stroke2– 6 and is a key performance indicator in the American Heart Association/ American Stroke Association Get With The Guidelines Stroke program,7 which have been followed in Taiwan.8 The mainstay in stroke prevention for patients with ischemic stroke in the Get With The Guidelines Stroke program is antithrombotic therapy.7 In addition to antithrombotics for stroke prevention, rehabilitation is an important therapy for facilitating functional recovery after stroke.9 Other than rehabilitation, stroke patients in Taiwan have the option of receiving complementary and alternative therapies including acupuncture that is approved for reimbursement by the National Health Insurance (NHI) in Taiwan.10 Acupuncture has been in practice among Chinese for more than 2000 years and has been increasingly integrated into the mainstream healthcare programs including those in the United States.11 In addition to various pain syndromes,9,12,13 acupuncture has increasingly attracted attention in treating stroke patients with mixed results.10,11,14–18 Meta-analyses suggest that the efficacy of acupuncture remains to be established.15,17 Despite the lack of solid evidence to support its clinical utility, acupuncture is a safe, low-cost, and viable alternative therapy, especially for patients with stroke-related disorders that do not respond to conventional medical or rehabilitative measures. www.md-journal.com |
1
Medicine
Shih et al
Favorable rehabilitation outcome aided by acupuncture in some stroke patients may increase physical activity to reduce stroke recurrence risk.19,20 Acupuncture may also have salutary actions on vascular function by increasing nitric oxide level, improving lipid profile, and lowering blood pressure.21–25 Pretreatment of electroacupuncture may reduce infarct size, improved neurological outcome in patients with cerebral infarction.26 Based on these ancillary effects of acupuncture that may all lead to lower stroke risk in stroke patients who receive acupuncture, we explore whether the incidence of stroke recurrence was lowered in stroke patients receiving acupuncture as compared with those without based on population-based claims in the National Health Insurance Research Database.
METHODS Data Sources Reimbursement claims in the NHI database were used in the present study. NHI has been implemented since March 1995, covering more than 99% of the 23 million population.27–30 The electronic database was encrypted with patient identifications scrambled to protect privacy of all subjects. This study was exempted from the review by the Internal Review Board. All beneficiaries’ inpatient and outpatient medical services such as simple demographics (gender, birth date, low-income status, and urbanization of living area), primary and secondary diagnoses with the International Classification of Diseases 9th Revision Clinical Modification (ICD-9-CM), procedures, prescriptions, and medical expenditures are recorded in the National Health Insurance Research Database established by the National Health Research Institutes.28-30
Ethics Approval Insurance reimbursement claims used in this study were from Taiwan’s National Health Insurance Research Database. For protection of personal privacy, the electronic database was decoded with patient identifications scrambled for further public access for research. This study was evaluated and approved by Taiwan’s National Health Research Institutes (NHIRD-100– 122) and the Institutional Review Board of E-DA Hospital, Kaohsiung, Taiwan (2014012); this organization’s regulations do not require informed consent because patient identification has been decoded and scrambled.28–30 This study was conducted in accordance with the Declaration of Helsinki.
Study Population In this cohort, 30058 adults (age 30 years) with ischemic stroke diagnosed for the first time in 2000–2004 were identified. Patients were then divided into 2 groups, without or with acupuncture therapy after stroke. We further randomly selected from those without acupuncture to constitute a control group that was matched by age, sex, and key variables with the acupuncture group, applying propensity score. Patients with ischemic stroke who were included in the acupuncture group received at least 6 sessions of acupuncture treatment. Only acupuncturists who are certified traditional Chinese medical doctor with acupuncture specialty fulfilling the yearly continuing acupuncture education requirements are qualified for filing NHI claims for acupuncture reimbursement. Patients with and without acupuncture treatment were followed from the index event until the end of 2009 to identify the incidence of stroke recurrence. Comorbidities including hypertension, diabetes, and hyperlipidemia were identified as the key stroke risk factors that might contribute to stroke
2
| www.md-journal.com
Volume 94, Number 39, October 2015
recurrence and compound the effectiveness of acupuncture treatment. Effects of medications for stroke prevention including antiplatelet agents, anticoagulants, and lipid-lowering agents on stroke recurrence were also assessed.
Criteria and Definition ICD-9-CM was used to define ischemic stroke (ICD-9-CM 430–434). Hypertension (ICD-9-CM 401–405), diabetes (ICD9-CM 250), hyperlipidemia (ICD-9-CM 272.0, 272.1, 272.2), liver cirrhosis (ICD-9-CM 571), mental disorder (ICD-9-CM 290–319), ischemic heart disease (ICD-9-CM 410–414), and renal dialysis (administration code D8, D9) were also identified.
Statistical Analysis The chi-square tests were used to compare the distribution of age, sex, comorbidities, and medication in reference to stroke recurrence between groups with and without acupuncture treatment. The incidences (per 1000 person-years) of stroke recurrence and incidence rate ratio with 95% confidence intervals (CIs) were derived and compared between groups. Stroke severity was assessed based on length of stay and hospitalization expenditure reimbursed by the NHI. The Kaplan–Meier plot was applied to measure stroke recurrence over time and the Cox proportional hazards model to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). All statistical analyses were performed using SAS software version 9.1 (SAS Institute Inc., Carey, NC) with 2-sided P < 0.05 being taken to represent statistical significance.
RESULTS Overall, there were 30,058 newly diagnosed cases of ischemic stroke. After matching with propensity score, there was no difference in age, sex, comorbidities relevant to stroke and medications for stroke prevention. In follow-up to the end of 2009, 4639 (30.9%) in the acupuncture group experienced stroke recurrence as compared with 5749 patients (38.3%) in the group without acupuncture (P < 0.001) (Table 1). The length of stay and hospitalization expenditure, 2 parameters that might reflect stroke severity, were not different between groups. The stroke recurrence rate per 1000 person-years was 71.4 in the group without and 69.9 with acupuncture treatment, respectively (P < 0.001) (Table 2). The reduced risk of stroke recurrence was associated with acupuncture treatment (HR 0.88, 95% CI 0.84–0.91). Acupuncture treatment appeared to reduce stroke recurrence rate in both sexes and across the age groups. Its effect was noted in patients with or without comorbidities relevant to ischemic stroke including hypertension, diabetes, or hyperlipidemia. Acupuncture effect in stroke prevention appeared to be more apparent among those not on medications for stroke prevention. Table 3 presents interaction of medication for stroke prevention and acupuncture treatment. The HR was also significantly lower in those with only acupuncture treatment. Compared with stroke patients without acupuncture treatment and medication therapy, the hazard ratios of stroke recurrence for those had medication therapy only, acupuncture only, and both were 0.42 (95% CI 0.38–0.46), 0.50 (95% CI 0.43–0.57), and 0.39 (95% CI 0.35–0.43), respectively. Compared with stroke patients with medication therapy but without acupuncture treatment, the HR of stroke recurrence for those with both acupuncture treatment and medication therapy was 0.93 (95% CI 0.89–0.97). In Table 4, the risk of stroke recurrence was associated with numbers of package of acupuncture treatment (P < 0.0001). Copyright
#
2015 Wolters Kluwer Health, Inc. All rights reserved.
Medicine
Volume 94, Number 39, October 2015
Acupuncture and Stroke Recurrence
TABLE 1. Characteristics of Stroke Patients With and Without Acupuncture Treatment
Acupuncture Treatment
Sex Female Male Age, yr 30–39 40–49 50–59 60–69 70–79 80 Mean SD Low income Coexisting medical conditions Diabetes mellitus Hypertension Hyperlipidemia Liver cirrhosis Mental disorder Ischemic heart disease Renal dialysis Medication use Antiplatelet agents Anticoagulants Lipid-lowering agents Admission to ICU Length of hospital stay, days Rehabilitation Stroke recurrence
No (N ¼ 15029)
Yes (N ¼ 15029)
P Value
n (%) 6502 (43.3) 8527 (56.7)
n (%) 6502 (43.3) 8527 (56.7)
1.00
160 (1.1) 1087 (7.2) 2896 (19.3) 5170 (34.4) 4773 (31.8) 943 (6.3) 65.7 10.4 191 (1.3)
160 (1.1) 1087 (7.2) 2896 (19.3) 5170 (34.4) 4773 (31.8) 943 (6.3) 65.7 10.4 191 (1.3)
1.00
6404 12,763 6093 729 4759 2779 219
(42.6) (84.9) (40.5) (4.9) (31.7) (18.5) (1.5)
14,086 (93.7) 687 (4.6) 6490 (43.2) 457 (3.0) 7.69 5.08 8678 (57.7) 5749 (38.3)
6404 12,763 6093 729 4759 2779 219
1.00
(42.6) (84.9) (40.5) (4.9) (31.7) (18.5) (1.5)
1.00 1.00 1.00 1.00 1.00 1.00 1.00
14,086 (93.7) 687 (4.6) 6490 (43.2) 457 (3.0) 7.77 5.21 8678 (57.7) 4639 (30.9)
1.00 1.00 1.00 1.00 1.00
®
OBSERVATIONAL STUDY
A Retrospective Cohort Study Comparing Stroke Recurrence Rate in Ischemic Stroke Patients With and Without Acupuncture Treatment Chun-Chuan Shih, MD, PhD, Chien-Chang Liao, PhD, MPH, Mao-Feng Sun, MD, PhD, Yi-Chang Su, MD, PhD, Chi-Pang Wen, MD, PhD, Donald E. Morisky, ScD, Fung-Chang Sung, PhD, MPH, Chung Y. Hsu, MD, PhD, and Jaung-Geng Lin, MD, PhD
Abstract: Little was known about the effects of acupuncture on stroke recurrence. The aim of this study is to investigate whether ischemic stroke patients receiving acupuncture treatment have a decreased risk of stroke recurrence. A retrospective cohort study of 30,058 newly diagnosed cases of ischemic stroke in 2000 to 2004 was conducted based on the claims of Taiwan National Health Insurance Research Database. The use of acupuncture treatment and stroke recurrence were identified during the follow-up period from 2000 to 2009. This study compared the risk of stroke recurrence between ischemic stroke cohorts with and without acupuncture treatment by calculating adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of acupuncture associated with stroke recurrence in the Cox proportional hazard model. The stroke recurrence rate per 1000 person-years decreased from 71.4 without to 69.9 with acupuncture treatment (P < 0.001). Acupuncture treatment was associated with reduced risk of stroke recurrence (HR Editor: Sarah Fogarty. Received: June 21, 2015; revised: August 13, 2015; accepted: August 19, 2015. From The School of Chinese Medicine for Post-Baccalaureate, I-Shou University, Kaohsiung (CCS); Ph.D. Program for the Clinical Drug Discovery from Botanical Herbs, Taipei Medical University (CCS); Department of Anesthesiology, Taipei Medical University Hospital, Taipei (CCL); School of Chinese Medicine, (CCL, MFS, YCS, JGL); Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan (CPW, CYH); Fielding School of Public Health University of California, Los Angeles, California (DEM); Department of Public Health, China Medical University (FCS); and Department of Neurology, China Medical University Hospital, Taichung, Taiwan (CYH). Correspondence: Jaung-Geng Lin, School of Chinese Medicine, China Medical University, 91 Hsueh-Shih Road, Taichung 404, Taiwan (e-mail: [email protected]). This study is based in part on data obtained from the National Health Insurance Research Database provided by the Bureau of National Health Insurance, Department of Health and managed by the National Health Research Institutes. The interpretation and conclusions contained herein do not represent those of the Bureau of National Health Insurance, Department of Health, or National Health Research Institutes. Dr C-CL has equal contribution with the first author. This study was supported in part by Committee on Chinese Medicine and Pharmacy, Department of Health, Taiwan (CCMP99-RD-035), Taiwan Ministry of Science and Technology (MOST103-2320-B-214-010MY2), Taiwan Ministry of Health and Welfare Clinical Trial and Research Center of Excellence (MOHW104-TDU-B-212-113002), China Medical University Hospital, Academia Sinica Taiwan Biobank Stroke Biosignature Project (BM104010092), NRPB Stroke Clinical Trial Consortium (MOST 103-2325-B-039-006), Tseng-Lien Lin Foundation and the Katsuzo and Kiyo Aoshima Funds, Japan. The authors have no conflicts of interest to disclose. Copyright # 2015 Wolters Kluwer Health, Inc. All rights reserved. This is an open access article distributed under the Creative Commons Attribution- NonCommercial License, where it is permissible to download, share and reproduce the work in any medium, provided it is properly cited. The work cannot be used commercially. ISSN: 0025-7974 DOI: 10.1097/MD.0000000000001572
Medicine
Volume 94, Number 39, October 2015
0.88; 95% CI 0.84–0.91). The acupuncture effect was noted in patients with or without medical treatment for stroke prevention but its impact decreased with aging of stroke patients. Compared with stroke patients without acupuncture treatment and medication therapy, the hazard ratios of stroke recurrence for those had medication therapy only, acupuncture only, and both were 0.42 (95% CI 0.38–0.46), 0.50 (95% CI 0.43–0.57), and 0.39 (95% CI 0.35–0.43), respectively. This study raises the possibility that acupuncture might be effective in lowering stroke recurrence rate even in those on medications for stroke prevention. Results suggest the need of prospective sham-controlled and randomized trials to establish the efficacy of acupuncture in preventing stroke. (Medicine 94(39):e1572) Abbreviations: CI = confidence interval, HR = hazard ratio, ICD9-CM = International Classification of Diseases, 9th Revision, Clinical Modification, NHI = National Health Insurance.
INTRODUCTION
S
troke remains a leading cause of death and the leading cause of disability worldwide.1 The costs of stroke to the family and the society underscore the importance of stroke prevention and management. Secondary stroke prevention remains a top priority in treating patients after the first stroke2– 6 and is a key performance indicator in the American Heart Association/ American Stroke Association Get With The Guidelines Stroke program,7 which have been followed in Taiwan.8 The mainstay in stroke prevention for patients with ischemic stroke in the Get With The Guidelines Stroke program is antithrombotic therapy.7 In addition to antithrombotics for stroke prevention, rehabilitation is an important therapy for facilitating functional recovery after stroke.9 Other than rehabilitation, stroke patients in Taiwan have the option of receiving complementary and alternative therapies including acupuncture that is approved for reimbursement by the National Health Insurance (NHI) in Taiwan.10 Acupuncture has been in practice among Chinese for more than 2000 years and has been increasingly integrated into the mainstream healthcare programs including those in the United States.11 In addition to various pain syndromes,9,12,13 acupuncture has increasingly attracted attention in treating stroke patients with mixed results.10,11,14–18 Meta-analyses suggest that the efficacy of acupuncture remains to be established.15,17 Despite the lack of solid evidence to support its clinical utility, acupuncture is a safe, low-cost, and viable alternative therapy, especially for patients with stroke-related disorders that do not respond to conventional medical or rehabilitative measures. www.md-journal.com |
1
Medicine
Shih et al
Favorable rehabilitation outcome aided by acupuncture in some stroke patients may increase physical activity to reduce stroke recurrence risk.19,20 Acupuncture may also have salutary actions on vascular function by increasing nitric oxide level, improving lipid profile, and lowering blood pressure.21–25 Pretreatment of electroacupuncture may reduce infarct size, improved neurological outcome in patients with cerebral infarction.26 Based on these ancillary effects of acupuncture that may all lead to lower stroke risk in stroke patients who receive acupuncture, we explore whether the incidence of stroke recurrence was lowered in stroke patients receiving acupuncture as compared with those without based on population-based claims in the National Health Insurance Research Database.
METHODS Data Sources Reimbursement claims in the NHI database were used in the present study. NHI has been implemented since March 1995, covering more than 99% of the 23 million population.27–30 The electronic database was encrypted with patient identifications scrambled to protect privacy of all subjects. This study was exempted from the review by the Internal Review Board. All beneficiaries’ inpatient and outpatient medical services such as simple demographics (gender, birth date, low-income status, and urbanization of living area), primary and secondary diagnoses with the International Classification of Diseases 9th Revision Clinical Modification (ICD-9-CM), procedures, prescriptions, and medical expenditures are recorded in the National Health Insurance Research Database established by the National Health Research Institutes.28-30
Ethics Approval Insurance reimbursement claims used in this study were from Taiwan’s National Health Insurance Research Database. For protection of personal privacy, the electronic database was decoded with patient identifications scrambled for further public access for research. This study was evaluated and approved by Taiwan’s National Health Research Institutes (NHIRD-100– 122) and the Institutional Review Board of E-DA Hospital, Kaohsiung, Taiwan (2014012); this organization’s regulations do not require informed consent because patient identification has been decoded and scrambled.28–30 This study was conducted in accordance with the Declaration of Helsinki.
Study Population In this cohort, 30058 adults (age 30 years) with ischemic stroke diagnosed for the first time in 2000–2004 were identified. Patients were then divided into 2 groups, without or with acupuncture therapy after stroke. We further randomly selected from those without acupuncture to constitute a control group that was matched by age, sex, and key variables with the acupuncture group, applying propensity score. Patients with ischemic stroke who were included in the acupuncture group received at least 6 sessions of acupuncture treatment. Only acupuncturists who are certified traditional Chinese medical doctor with acupuncture specialty fulfilling the yearly continuing acupuncture education requirements are qualified for filing NHI claims for acupuncture reimbursement. Patients with and without acupuncture treatment were followed from the index event until the end of 2009 to identify the incidence of stroke recurrence. Comorbidities including hypertension, diabetes, and hyperlipidemia were identified as the key stroke risk factors that might contribute to stroke
2
| www.md-journal.com
Volume 94, Number 39, October 2015
recurrence and compound the effectiveness of acupuncture treatment. Effects of medications for stroke prevention including antiplatelet agents, anticoagulants, and lipid-lowering agents on stroke recurrence were also assessed.
Criteria and Definition ICD-9-CM was used to define ischemic stroke (ICD-9-CM 430–434). Hypertension (ICD-9-CM 401–405), diabetes (ICD9-CM 250), hyperlipidemia (ICD-9-CM 272.0, 272.1, 272.2), liver cirrhosis (ICD-9-CM 571), mental disorder (ICD-9-CM 290–319), ischemic heart disease (ICD-9-CM 410–414), and renal dialysis (administration code D8, D9) were also identified.
Statistical Analysis The chi-square tests were used to compare the distribution of age, sex, comorbidities, and medication in reference to stroke recurrence between groups with and without acupuncture treatment. The incidences (per 1000 person-years) of stroke recurrence and incidence rate ratio with 95% confidence intervals (CIs) were derived and compared between groups. Stroke severity was assessed based on length of stay and hospitalization expenditure reimbursed by the NHI. The Kaplan–Meier plot was applied to measure stroke recurrence over time and the Cox proportional hazards model to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). All statistical analyses were performed using SAS software version 9.1 (SAS Institute Inc., Carey, NC) with 2-sided P < 0.05 being taken to represent statistical significance.
RESULTS Overall, there were 30,058 newly diagnosed cases of ischemic stroke. After matching with propensity score, there was no difference in age, sex, comorbidities relevant to stroke and medications for stroke prevention. In follow-up to the end of 2009, 4639 (30.9%) in the acupuncture group experienced stroke recurrence as compared with 5749 patients (38.3%) in the group without acupuncture (P < 0.001) (Table 1). The length of stay and hospitalization expenditure, 2 parameters that might reflect stroke severity, were not different between groups. The stroke recurrence rate per 1000 person-years was 71.4 in the group without and 69.9 with acupuncture treatment, respectively (P < 0.001) (Table 2). The reduced risk of stroke recurrence was associated with acupuncture treatment (HR 0.88, 95% CI 0.84–0.91). Acupuncture treatment appeared to reduce stroke recurrence rate in both sexes and across the age groups. Its effect was noted in patients with or without comorbidities relevant to ischemic stroke including hypertension, diabetes, or hyperlipidemia. Acupuncture effect in stroke prevention appeared to be more apparent among those not on medications for stroke prevention. Table 3 presents interaction of medication for stroke prevention and acupuncture treatment. The HR was also significantly lower in those with only acupuncture treatment. Compared with stroke patients without acupuncture treatment and medication therapy, the hazard ratios of stroke recurrence for those had medication therapy only, acupuncture only, and both were 0.42 (95% CI 0.38–0.46), 0.50 (95% CI 0.43–0.57), and 0.39 (95% CI 0.35–0.43), respectively. Compared with stroke patients with medication therapy but without acupuncture treatment, the HR of stroke recurrence for those with both acupuncture treatment and medication therapy was 0.93 (95% CI 0.89–0.97). In Table 4, the risk of stroke recurrence was associated with numbers of package of acupuncture treatment (P < 0.0001). Copyright
#
2015 Wolters Kluwer Health, Inc. All rights reserved.
Medicine
Volume 94, Number 39, October 2015
Acupuncture and Stroke Recurrence
TABLE 1. Characteristics of Stroke Patients With and Without Acupuncture Treatment
Acupuncture Treatment
Sex Female Male Age, yr 30–39 40–49 50–59 60–69 70–79 80 Mean SD Low income Coexisting medical conditions Diabetes mellitus Hypertension Hyperlipidemia Liver cirrhosis Mental disorder Ischemic heart disease Renal dialysis Medication use Antiplatelet agents Anticoagulants Lipid-lowering agents Admission to ICU Length of hospital stay, days Rehabilitation Stroke recurrence
No (N ¼ 15029)
Yes (N ¼ 15029)
P Value
n (%) 6502 (43.3) 8527 (56.7)
n (%) 6502 (43.3) 8527 (56.7)
1.00
160 (1.1) 1087 (7.2) 2896 (19.3) 5170 (34.4) 4773 (31.8) 943 (6.3) 65.7 10.4 191 (1.3)
160 (1.1) 1087 (7.2) 2896 (19.3) 5170 (34.4) 4773 (31.8) 943 (6.3) 65.7 10.4 191 (1.3)
1.00
6404 12,763 6093 729 4759 2779 219
(42.6) (84.9) (40.5) (4.9) (31.7) (18.5) (1.5)
14,086 (93.7) 687 (4.6) 6490 (43.2) 457 (3.0) 7.69 5.08 8678 (57.7) 5749 (38.3)
6404 12,763 6093 729 4759 2779 219
1.00
(42.6) (84.9) (40.5) (4.9) (31.7) (18.5) (1.5)
1.00 1.00 1.00 1.00 1.00 1.00 1.00
14,086 (93.7) 687 (4.6) 6490 (43.2) 457 (3.0) 7.77 5.21 8678 (57.7) 4639 (30.9)
1.00 1.00 1.00 1.00 1.00
